Advanced Primary Care Part II

1 work: N95.0 – POSTMENOPAUSAL BLEEDING

2. work Preeclampsia

Name: A.D Date: 02/2/2021 Advanced Directive: None

Allergies NKA Age: 40 Sex: Female

SUBJECTIVE

CC: 36-week routine prenatal exam, with headaches and swelling of hands and feet

HPI: 40 y/o white female presents at the clinic for 36-week OB appointment. Patient is P1,G0. Patient notes increase swelling in both hands and feet. She states that she ad headaches in the temporal area on 2 days last week rating a 6/10. She denies current headache. She also reports vison disturbances last week, but was informed by her ophthalmologist, this was a normal finding and did not call. Patient complete daily kick counts with greater than 10 kicks per hour. Patient has occasional contractions, but they resolve within 5 minutes after rest and do not follow a pattern.

Medications: Tylenol PRN for pain and Claritin

PMH: No present PMH Allergies: Denies any allergies to medications /yes environmental allergies seasonal Medication Intolerances: NKDA Chronic Illnesses/Major Traumas: Denies Hospitalizations/Surgeries Patient denies history of hospitalization or surgeries.

Family History: Mother and Father both alive with hypertension Mother is a Type 2 Diabetic. No family history of preeclampsia

Social History: Patient is a schoolteacher. She is married, in a monogamous relationship, with no prior children or pregnancies. Patient denies drug or alcohol use. Patient does not smoke. Patient does not exercise and eats a varied diet. Immunizations up to date, wears safety belt

ROS

General Positive for Fatigue, edema, and headache. Denies fever, chills, weight change, night sweats, fatigue, or change in sleep pattern Cardiovascular Denies any chest pain, palpitations, PND, orthopnea, edema

Skin Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Patient denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, or TB

Eyes No corrective lenses, blurring, visual changes of any kind Gastrointestinal Patient denies any abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ears Patient denies ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Patient denies urgency, frequency, burning, change in color of urine. Positive for increase in thick, clear discharge. Denies vaginal bleeding. Denies change in bowel or bladder habits, nutrition or appetite, and pain. Denies n/v/d. Contraception;, denies history of STDs Female: Last pap; 2020, breast, mammo 2020, no menstrual complaints, pregnancy hx G1 T0 P0 A0 L0

Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Musculoskeletal Patient denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Peripheral: Positive for generalize edema. Denies cyanosis or change in sensation.

Breast Denies pain, tenderness, or change in tissue Neurological Positive for increasing headaches. Denies LOC, seizures, weakness, or tremors.

Heme/Lymph/Endo No HIV hx, denies bruising, blood transfusion hx, night sweats, swollen glands, increased thirst, increased hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight 215 LBs BMI 28.5 Temp 97.5 BP: 178/92

Height 5.6 Pulse 88 Resp 18

General Appearance 40 y/o white female, very pleasant woman, in no acute distress, seated upright on the examination table, dressed appropriately with good hygiene. Maintain eyes contact during interview and answer all the questions appropriately.

Skin Skin brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT Head is normocephalic, atraumatic, and without lesions, hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinate’s. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular No chest pain noted. Heart rate is normal at 88, with intact distal pulses. S1 and S2 with S3 noted. No murmur, rubs, or clicks. No edema. PMI found at midclavicular line with no heaves, thrills, or lifts. Capillary refill less than 3 seconds.

Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal Abdomen: BS active in all 4 quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast: Normal Size. Symmetric. Nipples (1 each breast, midline to breast, no retraction of nipples, no discharge). Skin changes (no rashes, lesions, dimpling, retraction). No masses or tenderness. Pelvic Exam: External Genitalia: normal hair distribution, normal labia majora and minora, Bartholins and Skenes glands not enlarged, hymen, introitus normal with no drainage, perineum intact with no scars. No masses, lesions, excoriation, erythema, tenderness or discharge. Internal Genitalia: Vagina: pink, normal rugation, & normal tone. No cystocele, rectocele, discharge. Cervix: pink, No lesions, discharge. Cervix is dilated to a 4 and 60% effaced. Membranes are intact. Uterus: Fundal height measures at 37cm Adnexae: normal size. No masses or tenderness.

Genitourinary Bladder is nondistended; no CVA tenderness. External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted.

Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Deep tendon reflexes 2+/4 without a delayed relaxation phase.

Neurological No fine resting tremor of the outstretched upper extremity. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Speech is clear and fluent.

Psychiatric Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence, answers questions appropriately. no suicidal ideation

Lab Tests CBC. WNL. No evidence of HELLP syndrome. Platelets within range. 24 hour urine protein: positive for 0.4g of protein. Liver chemistries WNL Creatinine: 1.0mg/dL Fetal Stress test: reactive Antiphospholipid antibodies: negative Repeat Rh factor: negative Collect GBS swap if not already completed. Fetal ultrasound: Baby measures at 37w4days. Weight estimated at 7lbs5oz. Good movement and heart rate noted with FHR at 140. Urine dip stick with 2+ protein

Special Tests Ultrasound

ASSESSMENT FINDINGS AND PLAN

Primary diagnosis: Preeclampsia with severe features Differential Diagnosis: Gestational hypertension Preeclampsia Antiphospholipid Syndrome Routine gynecologic exam V72.31 Elevated blood pressure reading without HTN diagnosis 796.2

Administer rogam shot to prevent fetal loss in future pregnancies. Educate mother on need to go immediately to the hospital to start treatment and preparation for labor with a high risk ob/gyn (if not working in high risk clinic). Explain the need for IV labetalol to lower blood pressure and IV magnesium sulfate dosed at 6g over 20 minutes, followed by 2g/hour continuous infusion until 24 hours after delivery to help prevent seizures. Explain the birth plan to attempt to induce labor, however stress on the fetus or failure to progress could result in C-section delivery for safety. Educate the baby’s lungs are fully formed, measures at a healthy weight, and baby is old enough to be safely delivered. Have patient present to hospital for continuous maternal-fetal monitoring and labor induction. Preeclampsia is characterized by hypertension with proteinuria. This diagnosis generally occurs after 20 weeks of gestation in previously normotensive mothers, with most cases noted after 34 weeks of gestation. Because this patient is over a systolic of 160mmHg and has protein in her urine, she does not meet the diagnostic criteria of gestational hypertension. As she has these two characteristics, along with some visual changes and headache, she has too sever of symptoms to be classified as preeclampsia, and meets criteria for preeclampsia with sever features. Severe preeclampsia and blood pressures >160mmHg are indications for hospitalization and labor induction for maternal and fetal safety. As the patient does not possess antiphospholipid antibodies or thrombocytopenia, she does not meet the diagnostic markers for antiphospholipid syndrome. references August, P and Sibai, B. (2019). Preeclampsia: Clinical features and diagnosis. Retrieved from https://www-uptodate-com.proxy.library.maryville.edu/contents/preeclampsia-clinical-features-and-diagnosis?search=preeclampysia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1727029127. Norwitz, E. (2019). Preeclampsia: Management and prognosis. Retrieved from https://www-uptodate-com.proxy.library.maryville.edu/contents/preeclampsia-management-and-prognosis?search=preeclampysia&topicRef=6814&source=see_link#H31268927. Fox, R., Kitt, J., Leeson, P., Aye, C., & Lewandowski, A. J. (2019). Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. Journal of clinical medicine, 8(10), 1625. https://doi.org/10.3390/jcm8101625Name: A.D Date: 02/2/2021 Advanced Directive: None

Allergies NKA Age: 40 Sex: Female

SUBJECTIVE

CC: 36-week routine prenatal exam, with headaches and swelling of hands and feet

Medications: Tylenol PRN for pain and Claritin

Family History: Mother and Father both alive with hypertension Mother is a Type 2 Diabetic. No family history of preeclampsia

ROS

Skin Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Patient denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, or TB

Breast Denies pain, tenderness, or change in tissue Neurological Positive for increasing headaches. Denies LOC, seizures, weakness, or tremors.

OBJECTIVE

Weight 215 LBs BMI 28.5 Temp 97.5 BP: 178/92

Height 5.6 Pulse 88 Resp 18

Skin Skin brown, warm, dry, clean, and intact. No rashes or lesions noted.

Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal Abdomen: BS active in all 4 quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Deep tendon reflexes 2+/4 without a delayed relaxation phase.

Neurological No fine resting tremor of the outstretched upper extremity. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Speech is clear and fluent.

Special Tests Ultrasound

ASSESSMENT FINDINGS AND PLAN

This one is for pre-eclampsy

Postmenopausal bleeding:

HPI: Pleasant Hispanic female, 52 y/o, G0T0P0A0L0, that comes to the office staying “I have my period again”, she said that she has watery, bloody vaginal discharge for 2 weeks, her last menstrual period was 2 years ago, and since then she did not have any bleeding or discharge from her vagina, her husband died in 2016, and she did not have more sexual activity, the last pap test was on 2018, was negative. No history of sexual assault or trauma, also she refers mild discomfort on pelvic area, no fever, no chills, appetite preserved, no weight loss, no malaise, no weakness.

Current Medications: Aspirin 81 mg tablet, one tablet by mouth daily. Motrin 200 mg 1-2 tablet by mouth every 4-6 h if pain/fever, PRN. Vitamin C 500mg tablet, one tablet by mouth daily. Lisinopril 20mg tablet, one tablet by mouth daily. Hydrochlorothiazide 25 mg tablet, one tablet by mouth daily. Xanax 0.25 mg tablet, one tablet by mouth daily at bedtime.

PMH: HTN Anxiety GYN/OBY Menarche: 10 y/o. LMP: n/a. Menopause: 2 years ago. Length of cycle: n/a. Average number of days of menses: n/a. Characteristics of flow: n/a. Regularity of cycles: n/a. G0T0P0A0L0. HISTORY OF STIs: no Medication Intolerances: Sulfa

Screening Hx/Immunizations Hx: COLONOSCOPY:04/12/18 negative LAST PAP SMEAR: unknown around 2 years ago. History of abnormal PAP smear: no MAMMOGRAM:2019

Family History: Mother died/ CVA. Father died/ Colon cancer.

Social History: SMOKING STATUS: no ILLICITS DRUGS USE: no ALCOHOL USE: 1 cup of wine with dinner daily. OCCUPATION: Accounting. EDUCATION: Associated. MARITAL STATUS: Widowed

ROS

General No significant gain/loss weight, no fever, no chills, no malaise, no night sweats, no exercise intolerance. Cardiovascular Denies chest pain, no palpitations, no orthopnea, no edema, no claudication, no known murmurs, no history of cardiac disease or abnormal EKG.

Skin Denies skin rash, no wound, no change on skin color or texture, no change in a mole, no unusual growth, no dry skin, no itching, no jaundice. HAIR: Denies hair loss, no hair abnormalities. Respiratory Denies chest congestion, no SOB/DOE, no cough, no sputum, no hemoptysis, no wheezing, no snoring.

Eyes No irritation, no drainage, no dry eyes, no pain on eyes’ s structures or retro -orbital, no vision changes, no diplopia, no blurred vision. Gastrointestinal Positive for mild discomfort on lower abdomen, no other abdominal pain or discomfort, no bloating, no flatulence, no nauseas, no vomit, no diarrhea, no constipation, no changes on stools, no black tarry stools (melena) no blood in stools (hematochezia), normal appetite.

Ears Denies loss of hearing, no ear pain, no drainage, no sensation of ears feeling full, no ear ringing, no ears’ s trauma. Genitourinary/Gynecological Denies dysuria, frequency, urgency, hesitancy, incontinence, nocturia, hematuria. No history of UTI and kidney infections. EXTERNAL GENITALS: Positive for watery, bloody vaginal discharge for 2 weeks, no history of STD.

Nose/Mouth/Throat NOSE: Denies nasal congestion, no nasal drainage, no nosebleeds, normal smell sense. THROAT/MOUTH: Denies sore throat, no hoarseness, no difficulty swallowing, no postnasal drip. No mouth sore, no thrush, no bleeding gums, no lips sore, no teeth problems. Musculoskeletal No muscular aches or weakness, no arthralgia, denies history of falls, no pain during ambulation, no loss of balance.

Breast Denies chest abnormalities, no breast lumps, no nodules, no nipple drainage, no nipple retraction. Neurological Denies changes in LOC, Denies history of tremors, seizure, weakness, numbness, dizziness, headaches, memory lapses or loss.

Heme/Lymph/Endo Denies history of anemia, no bruising, no abnormal bleeding, no swollen glands. No excessive sweating, no cold/hot intolerance, no hot flashes, no abnormal thirst/ hunger/appetite, normal urinary habits. Psychiatric Denies anxiety, no depression, no irritability, no mood swing, no sleep disturbances, no hallucinations, no homicidal/suicidal though, no alcohol/drugs abuse, safe in relationships.

OBJECTIVE

Weight 164 lb BMI 27.3 Temp 97.5 F BP 116/70 mmHg

Height 5.5 Pulse 78 bpm Resp 20 rpm

PHYSICAL EXAMINATION

General Appearance well nourished, developed and dressed/groomed.

Skin Intact, warm, moist, good turgor.

HEENT Head normocephalic without evidences of masses or trauma. EYES: PERRLA, EOMs intact. Non-injected. Fundoscopic exam unremarkable. EAR: Ear canal without redness or irritation, TMc clear, pearly. Bony landmarks visible. THROAT: No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVJ distention.

Cardiovascular PMI not displaced, S1 and S2 RRR, no murmurs, no rubs, no gallops, no bruit. No varicose veins, no edema, Peripheral Pulses Present and Palpable in all extremities.

Respiratory Unlabored respiration, lungs clear to auscultation. Breath sounds normal.

Gastrointestinal Abdomen soft, mild tenderness on lower abdomen, non-distended, no masses, no scars, no herniation, no guarding, no rebound tenderness, bowels sound presents all 4 quadrants, no organomegaly, no bruits.

Breast Size: small, pendulous, symmetry. No skin changes, no rashes, lesions, dimpling, retraction, no masses, lumps, or tenderness, no discharge. Axilla WNL.

Genitourinary EXTERNAL GENITALIA: Mons poor gray hair distribution, no lesions, labia majora and minora, clitoris atrophic, Bartholin’s and Skene’s glands, Urethra, WNL. VAGINA: Atrophic, flaccid, no cystocele, rectocele. CERVIX: Small, no lesions, masses, inflammation, bloody discharge, negative for cervical motion tenderness, no ectropion. UTERUS: Big firm, lateral, hard and not mobile, tender to motion. ADNEXAE: Thickness of right parametrium. Ovarium not palpable.

Musculoskeletal No pain to palpation, normal gait and stance, ROM preserved on BUE/BLE.

Neurological Alert, oriented to time, place and person, neurologic grossly intact. Memory to recent and remote events preserved. Sensation intact to BUE/BLE, Preserved strength to BUE/BLE.

Psychiatric Insight: good judgement. Mood/Affect: normal mood and affect.

Lab Tests CBC with Diff, CMP, Lipid Panel, SR, UA, Vaginal and cervix culture, Pap smear test, Abdominal and Transvaginal US.

Diagnosis

N95.0 – POSTMENOPAUSAL BLEEDING

Differential Diagnoses:

Endometrial Carcinoma

Cervical polyps

Post-coital vaginal laceration

PLAN:

Medication: None at this moment.

Education: Patient educated on possible causes of post-menopausal bleeding, importance of lab/ test ordered to set diagnosis, management, when to contact physician.

Non-medication treatments: None at this moment.

Referrals/ Follow-up visits: Return in 3 days after lab/test done to be re-evaluated and referral to gynecologist if required.

References:

Hacker, N. F., Joseph, G. C., & Calvin, H. J. (2016). Hacker & Moore’s Essentials of Obstetric and Gynecology. (6 ed.). Missouri: Elsevier.

Papadakis, M. A., & McPhee, S. J. (2017). Medical diagnosis and treatment (56th ed.). San Francisco, CA: Mc Graw Hill Education.

discuses about each one and talk about the Diagnosis disease.

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